Workers’ Compensation Insurance Application
Business Information
Business Name
Address
City
State
Zip Code
Phone Number
Email
Employer Identification Number (EIN)
Contact Person
Contact Name
Contact Title
Contact Phone
Contact Email
Business Details
Type of Business
Years in Business
Description of Operations
Estimated Annual Payroll
Number of Employees
Employee Job Titles/Descriptions
Insurance History
Previous/Current Insurance Provider
Coverage Period
Claims/Accidents in Past 3 Years
Additional Comments
Comments/Questions